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Customer Interview – Advanced Pediatric Associates

This interview shares the perspective of Audra Bailey, Clinical Manager in charge of nurse triage at Advanced Pediatric Associates, a large multi-location pediatric practice in the suburbs of Denver. The triage department is staffed by dedicated triage nurses working in a small daytime call center at a separate office from their practice sites.

Here’s an overview of what we talked about:

Advanced Pediatrics Background

ClearTriage: It’s great to talk with you this afternoon! Could you start by telling me about Advanced Pediatric Associates?

Audra: Sure! Advanced Pediatric Associates is a large pediatric practice located near Denver, Colorado. We were founded over forty-five years ago and have grown to 25 providers in four different offices. Our providers are a mix of MDs, DOs, nurse practitioners and physician assistants. We work hard to be a medical home for the families we serve, to provide the personalized care of a small practice while providing the range of services possible with our large size.

ClearTriage: That sounds like a great practice for your patients. What’s your role at Advanced Pediatrics?

Audra: I’m the Clinical Manager. My role includes management of the triage nurse department, referrals department and our newly developed care coordination department. In addition, I also provide clinical insight and education to the medical assistant staff at each of the four offices.

The Triage Department

ClearTriage: That sounds busy! Can you tell me a little bit more about your triage department?

Audra: Sure. Our department staffs six triage nurses. Three of those nurses are full-time and the other three are part-time. I have four nurses working each day, however on Friday we are staffed with three.

ClearTriage: You don’t have more nurses on Monday mornings? I’ve heard some practices say that Monday mornings are much busier than the rest of the week.

Audra: Just four. It works because I monitor the call queues. If I’m needed in the queue, I will occasionally jump in and help so the wait times are not as long.

ClearTriage: Because you’ve had experience as a triage nurse?

Audra: Yes. That was my first job when I started here at the practice. I was a triage nurse and then I eventually moved into the management role.

ClearTriage: It’s interesting that you have dedicated triage nurses rather than having those nurses also work with patients as they come into the office. What do you do when the triage volume is low?

Audra: We have an assigned rotation each day. Incoming triage calls are the priority so the nurses always have to be ready to answer the phones. In addition to that, they each have an assigned daily rotation that includes returning messages, prescription refills, prior-authorization requests, and monitoring provider in baskets. So they all have their own tasks that they complete in between answering live phone calls.

Triage and the Providers

ClearTriage: Nice! Your providers who own the practice obviously value triage. They’re supporting it with the resources, what are they looking to provide to your patient base? In other words, why do you do triage?

Audra: Triage has always been an important service here at Advanced Pediatrics. It’s great to be able to provide that added benefit to a family who maybe is on the fence on whether or not they really need to bring their sick child in. Just knowing that they can call in and talk to a nurse and that nurse can guide them through questions, answers and determine what is the best thing for that child. I feel the partners of the practice have always been strong supporters of triage because they too believe that it’s a great benefit to the families here at Advanced Pediatrics.

In addition to that, triage also gives the providers some of the background information that they might need on a more complicated patient coming in the door. We have the triage nurses here to discuss behavior concerns like picky eating or potty training, along with depression and anxiety. So that way, before the provider even gets in the door with the patient, they have a little bit of a background with the triage note.

ClearTriage: So the providers review the triage notes before they see the patient?

Audra: Yes, absolutely they do.

ClearTriage: Do they review every triage note?

Audra: No, we don’t have anybody that goes through all of the notes at the end of the day. Just based on volume alone that would be really difficult to do. The providers are all very comfortable with the protocols that support the triage nurses. And if there is something in a protocol that maybe needs adjustment, they’re not afraid to discuss that with me. We review these suggestions with our clinical committee group to determine whether there’s something in a protocol that needs to be changed. That same group reviews our standing orders and policies so our nurses can manage the prescription refill process. Having the nurses do this means the providers can focus on the needs of the patients and families.

ClearTriage: That makes sense. We were at a conference where some of the attendees were saying they didn’t offer triage to their patients because they view triage as paying nurses to have patients not come in, resulting in less revenue for the practice. Other people believe that triage nurses free up the providers to do things that bring in more revenue. Plus the quality of life benefit – the providers aren’t dealing with all of these things that take up time but don’t bring in any revenue after they finish a busy day seeing patients.

Audra: Yes. We do value the time and cost of our triage nurses to the practice. And we know that some people think that triage encourages patients to receive medical care by phone instead of in the office. So we encourage patients to use our website when they have questions – it has Dr. Schmitt’s parental triage guidelines which helps them decide when to call our office. But in the end, we think that our triage nurses ensure that our patients are getting the right care at the right time in the right place.

And I also think it is very beneficial because if you have a mom that’s been trying to potty train her three-year-old and everything she has tried has failed, the triage nurse is there to assist her with other ideas within the protocol, without having to send a message to the provider. The nurses can set up a consultation visit to further assist the family, to make sure there is nothing physically wrong. It really serves as a benefit for all. Being a large practice, the triage nurses can help take some of that strain off of the providers themselves. Our provider’s schedules are full – there are plenty of appointments.

ClearTriage and Epic

ClearTriage: You mentioned the protocols. How long have you guys been using Dr. Schmitt’s protocols?

Audra: Well, I’ve been here for 12 years and we’ve used them all of that time, and I know they were using them long before, so probably close to 20 years.

ClearTriage: How did you wind up making the decision to use ClearTriage rather than the book version of the protocols you were using previously?

Audra: The majority of our work is computer-based, so using a software program that allowed the nurses to have the protocols visually in front of them was much more efficient. Having everything on screen allows the triage process to flow from the onset to completion of the call. This leads to shorter call times and better documentation.

ClearTriage: What EMR are you using with ClearTriage?

Audra: We are currently on Epic as part of our relationship with Children’s Hospital Colorado.

ClearTriage: And ClearTriage is working well with Epic for your nurses?

Audra: Absolutely, ClearTriage has been wonderful for that piece.

ClearTriage: Did you ever look into using Epic’s Nurse Triage Module?

Audra: We did, but I kind of hit roadblocks there. When I would ask about it, the comments that I got back were that it was kind of clunky and hard to maneuver around. And then ClearTriage became available and it was an easy way to implement our triage in Epic.

Finding Good Triage Nurses

ClearTriage: How do you find a good triage nurse for your team?

Audra: That’s an interesting question, because not everybody can do this job. I think that the nurses I have found really enjoy what they are doing. They are ok not having face-to-face contact with patients. A telephone triage nurse has to be a good listener as well as having excellent critical thinking skills. Even though they don’t have their eyes on the patient, they still have to come to an accurate assessment. It can be quite challenging to tease it all out over the phone.

ClearTriage: Have they all worked directly with patients before?

Audra: Absolutely. We don’t normally hire anybody that doesn’t have at least two years of experience on the floor or in a clinical setting of some sort.

I think in the interview process, you definitely have to give scenarios, to pretend you’re the mom calling: “I’m calling in about my child, this is what’s going on…” This is without the protocols, which is nice because it lets me see if they can troubleshoot based on the information given, ask questions, and think outside of the box.

ClearTriage: Are you using easy, direct scenarios? Or complicated ones where you want them to probe deeper? Or both?

Audra: A little bit of both. There might be a scenario about a child who’s had vomiting and diarrhea for three days. Or there might be a trauma, where the decision would be to direct the parent to call 911. For that scenario I wouldn’t want them to start asking too many questions since it should be clear out of the gate that it’s a true emergency.

Training Triage Nurses

ClearTriage: And once you find a nurse, how do you train them?

Audra: We used to do a fairly long orientation process with new nurses, where we would have them orienting with somebody anywhere from six to twelve weeks. We’ve really condensed that and I think ClearTriage has helped in that regard. They’ll start by spending a week in scheduling where they learn how to schedule appointments and get the flow of being able to talk to somebody at the same time that they’re maneuvering in our computer systems.

Then when they come to triage, they’re with an experienced, seasoned triage nurse and will just observe for a couple days. I think that observation is key, just to see how a nurse maneuvers from triaging in ClearTriage to getting their note into Epic to scheduling the appointment or doing home care. And once they’re finished with that observation process, anywhere from two to four days depending on their comfort level, then we have them start navigating the system by having our experienced triage nurse talk to the family while the new nurse is actually maneuvering the system and going from screen to screen and doing the documentation.

ClearTriage: So they’re both listening at the same time?

Audra: Correct. Their headsets are synced. We do that for two to three days, just to see how they’re doing. And then after that, they’ll do both the talking and the typing.

ClearTriage: Do they still have the nurse paired with them?

Audra: They do. That way the experienced nurse can jump in if they’re having any trouble, or not going to the right protocol, or simply just learning the guidelines of the practice. Typically they’ll do that for three to four days, until they’re feeling comfortable. We’ll then do a five-call evaluation. The nurse that has trained them will listen to five of their calls just to be sure that we’re comfortable with how they’re answering the phone, assessing customer service and if they’re getting the pertinent information. Are they choosing the right protocol? Right disposition? Giving the right advice? Once they pass that evaluation they’re ready to take calls on their own. And I’ll periodically listen to their calls from my desk as well.

ClearTriage: Are the triage nurses all sitting in the same area so they can talk to each other if needed?

Audra: Correct.

ClearTriage: I think that would help with the transition. You’re just starting to work independently; if you have any questions, you’ve got people there to talk to. As opposed to a practice with just one triage nurse or with multiple sites that have the nurses scattered. They’re there as a team to help each other.

Audra: Absolutely. They can put the caller on hold and then they can talk to their fellow triage nurse or come in and ask me a question. “I’m not sure where this is going, can you give me an idea of…” or “I’m thinking this child needs to be seen more urgently than what the protocol is saying” – those kinds of things. So yes, it’s always very easy to ask a question.

ClearTriage Documentation Options

ClearTriage: ClearTriage has different documentation options: whether you want to document all the pertinent negatives or just the first positive, what level of care advice to document. I know when you started there were some discussions and even disagreements between your nurses on how they wanted to document. What did you wind up deciding? How did you wind up deciding that?

Audra: We ended up just documenting the first positive triage question. And it was a little bit of a struggle. We have a nurse on staff that has been triaging for a number of years, so it was very important to her that each question was documented as a “no” until we got to the first positive question. It brought up many conversations about charting by exception, the pros and cons. But we tried it a couple different ways and I think once everybody got in the routine of having a more condensed format, it kind of rang true that “Oh, yeah, this is actually a better way to document a call.” It also improved our call times. Not that you want to always be quick on a call, but there are times when queues are high and you really need to get what you’re doing done and move on to the next caller. So that way we’re helping our patients out in a timely manner.

ClearTriage: And it’s still giving your providers enough information?

Audra: Absolutely. And that was the other piece – the providers. We asked them about the different documentation styles: Which is easier for you to read? Can you get enough information out of this note? They were absolutely fine with the more concise documentation option.

Average Call Times

ClearTriage: If there was a practice that was thinking of using ClearTriage, any ideas that you would share with them?

Audra: I think just having them try it. Doing a trial to see if it’s something that’s going to meet their needs as a practice. Because I do think every practice is different but I would explain to them that since we’ve been using ClearTriage, we just really feel like it’s been a more efficient use of our triage nurses’ time. We rarely have long call wait times because the nurses are able to get through the triage questions, determine the right disposition, schedule an appointment or give the home care advice, give call back instructions and complete the call documentation.

ClearTriage: Do you track call times? It’s a question I get periodically and that I see fairly regularly on the AAACN listserv. There’s a wide range in answers, from “Our target is three to five minutes per call” to “Our calls take fifteen to twenty minutes.”

Audra: Our calls average between six and eight minutes per call. Obviously, there are some depression or behavior calls that will go as long as twenty minutes. But for the most part, it’s about six to eight minutes a call.

ClearTriage: I heard a rhyme about call times recently: “The sicker, the quicker”.

Audra: Absolutely. Because you’re going to want to get off that phone and get that patient scheduled or to the ED.

Call Center vs. Practice-Based Triage

ClearTriage: You previously worked at the Children’s Hospital Colorado call center, didn’t you?

Audra: I did.

ClearTriage: What are some of the differences between working as a triage nurse in a practice versus in a call center?

Audra: When I was working in the hospital call center it was usually after hours and the families didn’t have access to their primary care providers. The options for care were more limited and the questions in the after hours protocols reflected that. You didn’t want to send the child into the emergency room if it wasn’t truly necessary. But you also had to make sure they were safe to wait at home until their doctor opened the next day. I think we have a little bit easier decision during office hours because we know that if there is a child that really needs to be seen, odds are good we’re going to be able to get them in and get them taken care of.

ClearTriage: I’ve heard Dr. Schmitt describe something similar in the difference between the office hours and the after hours protocols themselves. The office hours protocols lean a little bit more toward bringing the child in because the practice is open, it’s easy and safe to do. Rather than having the child get in a situation where they need to go to the ED in the middle of the night.

Audra: You do get a little of that after hours experience in a practice when you’re nearing the end of the day. You’ve got those after school callers and you may not have a lot of after school availability. Again, it’s do we need to send that child into urgent care or the ED, or can they wait until tomorrow?

ClearTriage: In the practice, do the nurses talk a little bit more to the providers in that situation?

Audra: Yes, they’ll talk to the providers if they have questions, especially if it’s between those four and five o’clock hours. Let’s say you’ve got a baby that may be starting an ear infection. Is it really dire so they have to go into the emergency room, or can we get them in first thing in the morning? If Mom can manage through the night with some home care advice, then that would be the best way to serve these patients instead taking a child into the ED, exposing them to whatever else is out there. The triage nurses are very good about utilizing one another as well.

Wrapping Up

ClearTriage: Okay. Anything else that you think we should talk about? I think your centralized department could be a great model for larger multi-site practices.

Audra: I think it is very interesting, the way the practice does triage here. It’s great because our number one concern is our patients. For the practice to be able to provide this service, to hire nurses in this capacity – it speaks volumes as to how we are caring for our patients. Like I said, our triage nurses have decided this is what they like, this is what they want to do. I think it’s really broadened their skills because you have to be so much more in tune with what the caller is telling you because all you can use is your ears and your ability to communicate with the families. For some, it might terrify them. “Oh my goodness, I can’t see the patient in front of me, what am I doing?” Whereas the staff that we have hired here, they love what they do, they enjoy talking to parents over the phone and being that helpful component in our practice.

ClearTriage: Sounds like you’ve got a great group. Thanks for your time today, I really appreciate it!

Audra: Of course!

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